PROFESSIONALISM, CARING, AND NURSING, 1990 (By Eliot Freidson, paper prepared for The Park Ridge Center, Park Ridge, Illinois.)
¶1 From its very beginning as a modern occupation, nursing has been preoccupied with its status both in society at large and in the institutions that provide health care. In the English speaking world the initial effort was to make nursing a socially respectable, full-time occupation grounded in the authority of both training in the clinical arts and the orders of physicians. Throughout the best part of this century, however, particularly in the United States, nursing has had larger ambitions. It has increased training and licensing requirements and persisted in its search for greater independence.
¶2 The key-word in English-speaking countries for this movement to improve an occupation's position is "professionalization". But like most such words it is an ambiguous one, used more often symbolically and globally than precisely and concretely. As a word it represents discontent with the present position of an occupation and ambition to improve it, but insofar as the word is used globally it provides no resources for either understanding the occupation's present position or for choosing the concrete strategies that can improve its future position. Here, I should like to contribute to advancing the social movement of nursing by discussing what can be designated analytically as the distinctive characteristics of professionalism, then examining the extent to which nursing in the United States today manifests those characteristics, and finally discussing how professionalism bears on the problems faced by nursing. In my discussion I shall emphasize the theme of "caring" that seems to figure prominently in conceptions of nursing today. As it happens, it also figures in conceptions of profession.
THE TWO MEANINGS OF "PROFESSION"
¶3 Taking the word "profession" broadly, I believe we can recognize two basic denotations. (See Freidson 1988b: 21-6.) First, consonant with the Latin origin of its use in English, it represents a more than ordinary commitment to performing a particular kind of activity--an avowal of a special sort of devotion or dedication. In the context of present-day discussions of the tasks of nursing, it represents caring about the well-being of those one serves. However, the other basic denotation is quite different--it is the productive labor by which one makes a living, a full-time occupation that entails the use of some sort of specialized skill. Each of these quite different denotations can stand by itself. One can care and provide care without having to possess and exercise any particularly specialized knowledge and skill. And one can perform the task of giving care to another without caring.
¶4 Profession is a distinctive concept only when it fuses the two basic denotations, but one cannot understand how that fusion can exist in a stable institution without bringing in other characteristics. Insofar as nursing is an occupation, it must have a position that provides both access to people to nurse and the regular income necessary for allowing one to spend a great deal of time at nursing rather than some other job. Its members must have the training that makes them identifiable as qualified nurses who can find work to practice nursing, and that in turn presupposes arrangements by which training, credentialing, and work are provided. Furthermore, the character of training and practice institutions establishes the limits within which nursing activities can take place. Thus, one must pay close attention to the institutions that structure caring and giving care because one cannot even be, let alone practice as, a professional nurse outside them. In order to identify the distinctive institutions of professionalism, however, we must look more closely at the idea of profession.
TWO APPROACHES TO CONCEIVING OF PROFESSIONS
¶5 Methodologically, there seem to be two basic ways to try to make sense of the idea. One of them attempts to create an intuitively satisfying conception that takes into account most if not all of what everyone has in mind in using the word, and a common denominator for the attributes of most of the occupations that many call professions, as well as for the historic process by which they became professions. It is, in short, inductive, trying to create a coherent concept by abstracting from observed phenomena of both verbal usage and occupational life. On the whole, I should say that most conceptions of profession, academic and otherwise, adopt that strategy.
¶6 There are many difficulties with that approach, not the least of which is its helpless dependence on national differences in both linguistic usage and occupational institutions. In the case of usage, even in English there is not one but many, and among the alternatives are diametrically opposed meanings--on the one hand, any occupation by which one gains a living (which is the ordinary French usage), and on the other, only a handful of occupations with distinctive characteristics. Many of the characteristics of so-called professions in the English-speaking world are a function of special national histories in which the state has merely ratified the efforts of private occupational groups to organize themselves. In other nations, however, the state has created and organized many of the occupations that today we are inclined to call professions. Their civil service rather than independent professional status is reflected in the different character of their occupational institutions.
¶7 In the light of such empirical variation in both usage and occupational institutions from one country to another, one is hard put to find common denominators that have very much substance. My own recent effort (Freidson 1988b: 59-60 ) defined a profession as any occupation whose members can find work only when they possess a credential testifying to successful completion of a training program connected with higher education. Such a definition is useful because of its breadth, and can distinguish among occupations in any nation, English-speaking or not. But insofar as it leaves out one of the two central meanings of the term--commitment, devotion, caring--it is impoverished. Furthermore, it does not specify the characteristics of occupational organization, training, relations with other occupations, and relations with consumers, employers and patrons that distinguish professions from other occupations. The potential richness and importance of what is evoked by the word has been lost.
¶8 Far more analytically useful, I believe, is a quite different approach to conceptualization, one that seeks to liberate itself as far as possible from one particular time and place and addresses professions as variable historic examples of a more general, abstractly defined phenomenon--a circumstance in which occupations control the terms, conditions and goals of the work they do. As Johnson noted, a profession can be seen as "a peculiar type of occupational control rather than an expression of the inherent nature of particular occupations". (Johnson 1972: 45.) It can be considered to be an alternative to other ways of exercising control over work that are quite familiar to us. Indeed, its distinctiveness can be much more readily grasped when one compares it to those alternatives. By delineating an abstract, conceptual model of professionalism, I think we can retain the conceptual richness of the historic idea while avoiding the confusion of trying to reconcile the conflicting and overlapping historical usages and practices to be found in both everyday and official life in various nations. Informed by knowledge about the historical occupations that have been called professions in the English-speaking world, this is what I shall do here.
¶9 In considering this model, it is important to note that it is not intended to describe faithfully what all occupations that happen to be called professions are like. Rather, it is what Max Weber called an "ideal type," a logically consistent model whose features represent what is believed to be essential for a particular outcome--here, self-governing occupational groups. It is a method of conceptualization intended to display the most important elements of a particular way of doing things. It is intended to sort out the essential from the epiphenomenal, and lay bare the assumptions upon which they rest. It will be compared to similarly abstract models for the organization and control of work that are more familiar to most people--the free market, where the consumer reigns supreme, and the rational-legal or bureaucratic market, where the official commands.
¶10 In evaluating all three models, it is essential to keep in mind their logically ideal, abstract character. They are all manifested in health care today, but incompletely, and with their underlying assumptions often unstated and unacknowledged. In their "pure" form, they represent mutually exclusive, alternative methods of organizing work, for each is predicated on a radically different set of assumptions and goals, with the controlling voice given to quite different agents. Each is also a kind of vision, a utopian ideal to be pursued as well as a merely descriptive model..
THREE MODES OF CONCEIVING OF WORK
¶11 The perfectly free labor market. Let me begin with the model that is most familiar to us today, invoked as it is by virtually all politicians in the United States and especially emphasized in policy-making designed to contain the cost and improve the efficiency of American health care--the perfectly free labor market. The source of its organization is the aggregate outcome of the unplanned choices of individual consumers who are fully informed about the characteristics of what is being offered for sale and who rationally calculate their material self-interest in making their choices. Their primary criterion for choice is economic cost.
¶12 The workers in that labor market act purely as individuals, and without any organization. Their primary desire is to obtain the highest possible income, and they have complete knowledge of available work and what it pays. They have no particular commitment to any particular locality or kind of work and move freely to whatever work offers the highest income. The work they do is a function of what consumers want and the price they are willing to pay for it. The outcome of these conditions is the production of a wide variety of goods or services at the lowest possible cost.
¶13 The rational-legal or bureaucratic labor market. Markedly in contrast to the free labor market is the bureaucratic market. Whereas the former is unplanned, the latter is deliberately organized and planned by a central authority that has decided to produce a set of goods or services whose characteristics it has specified and that has chosen how to produce it. Its executives and staff decide what kinds of tasks must be performed to reach their productive goals, create positions or jobs, hire people to perform them according to their own criteria of necessary qualifications, and establish a hierarchy of supervisory positions to assure that the orders of the executive will be transmitted throughout the organization, and obeyed. The structure of jobs it organizes is rationally developed, with careful attention to written rules specifying the qualifications required for each job, the responsibilities it entails, and the rights of its incumbents. In order to effectively control the work that is done, it attempts to routinize the tasks of its workers so as to minimize the use of discretionary judgment and maximize the use of objective, measurable criteria by which to evaluate them. And it attempts to standardize the services or goods it produces so that their quality is uniform. Workers are bound into the bureaucratic labor market by the prospect of predictable increases of income that its rules assure, by the possibility of promotion, and by the security of seniority or tenure and the prospect of a retirement pension.
¶14 The occupationally controlled labor market. Whereas the free market is controlled by the consumer and the bureaucratic market by the official or executive, the occupationally controlled or professional market is controlled by specialized workers organized into corporate groups. In the free market the consumer determines what work is to be done, by whom, for what price and what expected service or product. In the bureaucratic market it is the official who makes those determinations, influenced, no doubt, by some conception of what consumers need or want. In the professional market it is the worker who makes the decisions. The occupational group determines whom it recruits, how they shall be trained, and what tasks they shall perform. It has a monopoly in the labor market over a specific set of tasks, an exclusive jurisdiction. Furthermore, members of the occupation have the exclusive right to evaluate the way their tasks are performed and the adequacy of the goods or services their work produces. Neither lay executives in work organizations nor individual consumers have authority over the performance and evaluation of professional work.
¶15 Since this model is not as well established conceptually as the others, it needs more elaboration here. One of its central features is collegiality or solidarity (see Waters 1989: 945-72), something that is essential if the occupation is to be a corporate group rather than a mere aggregate of individuals who happen to do the same kind of work. Collegiality is developed in a number of ways, not the least among them being a relatively long training experience that socializes them into the occupation (see Fox 1989: 46), a common occupational identity, shared dependence on their protected monopoly in the marketplace, formal or informal rules that limit the intensity and character of the way they compete with each other for success within their own market, and also, I suspect, a shared sense of vulnerability to attacks by potentially competing occupations seeking to breech their jurisdictional boundaries ( see Abbott 1988), and by others who resent their monopoly.
¶16 In the professional labor market the primary interest of the workers is more in the quality of their work than in its reliability or cost. In the free market workers are committed primarily to the income they gain from whatever work they do. In the bureaucratic market they are committed primarily to their positions or jobs, and their secure and predictable careers. In contrast, the protected economic position provided by the professional market makes it possible for its workers to develop commitment to a life-time career of performing their work, and to the work itself as a central life interest. Commitment is to the intrinsic quality of the work for its own sake, with its cost and even its reliability being secondary. Interest is in the rare and the intellectually challenging rather than in the routine, honor being given to colleagues who attack unusual problems creatively. Routinely reliable and inexpensively accomplished work receives little applause within the collegium.
¶17 It is important to understand that none of these markets is self-sustaining. Each requires political and economic support by forces that stand outside them. The elementary conditions necessary for a free market require that the state or some other effective agent exercise power to enforce contracts, prevent monopoly, monopsony, and other conspiracies against free competition, and to assure the availability of full and accurate information to all the participants. In order for the bureaucratic market to exist, some effective external power must charter or license it so as to provide it with the effective authority to control its enterprise. Similarly, the professional market cannot exist without some external support for sustaining its characteristic monopoly. How and why is that support gained?
¶18 Support is gained by invoking the hypothetical promises of the model itself. If we can create the enabling circumstances for a perfectly free market, the policy argument goes, we will gain, as Adam Smith put it, "universal opulence"--the greatest amount and variety of goods and services at a cost low enough to make them available for all. Similarly, if the circumstances required for bureaucratic authority and control over production are supported, workers can be assured of fair and secure positions based on their qualifications and performance alone, and consumers can be assured of reliable services and products, even if not of the greatest variety or at the lowest cost.
¶19 The professional market, in contrast, invokes a different desideratum--namely, work of benefit to consumers whether they recognize or desire the benefit or not. Those representing the profession claim that a free market is inappropriate for the kind of work they do because the work is so complex and esoteric that no one but members of the occupation can fully comprehend and adequately evaluate it. Lay people, in short, are in no position to make rational, fully informed choices. Furthermore, poor or inappropriate services can have serious, even dangerous consequences for the consumer's well-being. Thus, for their own good consumers should not be allowed free choice; a monopoly must be provided to the profession to make choices on their behalf. The professional claim therefore rejects the propriety of using the free market model on the ground that consumers are not equipped to play the commanding role that lies at its center. (See Dingwall amd Fenn 1987: 51-64.) As Arrow (1963) put it, "Delegation and trust are the social institutions designed to obviate the problem of informational inequality."
¶20 The bureaucratic mode of organizing labor is also rejected as an alternative by the argument that professional knowledge and skill cannot be standardized, or reduced to rational rules of procedure or performance without destroying its value. (Arguing this for health care. see Freidson 1989.) In order to provide consumers with services that fit their individual circumstances, professional work requires discretionary judgment, and can be effectively organized and supervised only by professionals who have been trained in such judgment.
¶21 Central to the mandate of the professional market, therefore, is trust in the competence and integrity of professionals--trust that they will not turn their monopoly to their own advantage, that they will care and that they will take care to control both themselves and their colleagues in order to ensure that the public is not victimized. Typically, proponents of occupationally controlled labor markets argue that members of their occupation are both selected and trained to be ethical in their work, caring more for the quality of their work and the good of the consumer than for their own personal gain. Insofar as some few deviants might slip through the selection and credentialing process, however, the claim is that the organized occupation can be counted on to seek out and either correct or expel those few who may violate the consumer's trust.
THE EXCLUSIVENESS OF THE MODELS
¶22 It should be clear that in their fully developed logical form, each of these modes of organization is hostile to the other. The free market does not permit either the development of occupational groups and solidarity among workers, or the development of hierarchically organized control of workers because each represents a conspiracy against free choice by both consumers and workers. Furthermore, the free market assumes that people are motivated solely by material self-interest, and so discourages trust between workers, and between workers and consumers. In order to protect their interests, all participants in the free market must continuously examine each others' offers critically in order to ensure that they will not be victimized by fraud. The free market also denies that either occupationally controlled or centrally planned and administered work can produce goods and services efficiently. And finally, the free market values the cost of goods or services over either their reliability or quality. As I have pointed out elsewhere, in the real world, where elements of all three models exist side by side, a critical and often ignored policy issue lies in deciding which model is to dominate the organization of a market, for heavy emphasis on one is likely to cancel out the potential virtues of the others. In the case of the health care system, policies which strongly emphasize either the free or the bureaucratic market can undermine both the trust and the concern with the intrinsic quality of work that lies at the heart of the professional model. (Freidson 1990.)
NURSING AND THE HEALTH CARE DIVISION OF LABOR
¶23 In an effort to clarify the essential elements of professionalism, I have compared a "pure" model of it with others designed to organize the control of work. But reality is never pure. Health care today is not carried out by members of individual occupations, each going their own way. Medicine, nursing and other health care occupations are part of an organized and coordinated division of labor, their members working together around individual patients and their problems. The relations these occupations ordinarily have with each other have a great deal to do with the way they can do their work and control it themselves.
¶24 There is in fact more than one way to organize those relations into a division of labor. In a free market, differentiation into separate jobs and occupations is likely to be quite fluid, with few stable jurisdictions and people offering to provide consumers with various mixes and blends of tasks. Without the constraint of such things as licensing or formally defined and fixed jobs in an organization, one can imagine some offering to do both curing and nursing. In a bureaucratic market, managers determine what tasks are to be organized into jobs and positions, and how they are to be interrelated and coordinated so that the variety of possibilities is considerably more limited. In a professional market, occupations negotiate the boundaries of their jurisdictions with each other, and establish the ways in which the tasks of each are coordinated. Clearly, both the source of authoritative organization of a division of labor and its particular place in that organization are critical to any occupation. Certainly it is critical for the position of nursing.
¶25 In the present division of labor within American health care we can distinguish between occupations that have an autonomous position and those that do not. (See Freidson 1988a: 47-50.) Dentistry, to take one familiar example, is autonomous. Dentists work with a clearly delineated set of problems over which they have exclusive jurisdiction, and work independently of physicians. If one imagines a division of labor as an "industry" composed of different occupations all engaged in pursuing some specialized portion of the comprehensive goal of preventing and curing human ills, one can see the dentist's position as one that is separated from and independent of the physician's. Not all health care occupations are in such an autonomous position, however. In the structure of work roles surrounding dental treatment, the dental hygienist, at least in some states, would be found subordinate, subject to the dentist's supervision and direction.
¶26 Similarly, American nursing's position in the health care system is not autonomous. It is true that it does have a monopoly over particular jobs requiring the R.N. And it is organized into corporate groups that control recruitment and training policies. Yet it is only one of a number of occupations that cooperate in the division of labor composing health services. Unlike some of those occupations, nurses seem to have difficulty claiming a set of tasks whose boundaries are clearly defined, stable from one circumstance to another, and performed exclusively only by those with their special training. Many of their claimed tasks can be performed by members of other occupations, some by those with considerably less training. Hospital administrators and physicians are often free to choose between nurses and others to perform particular tasks. Furthermore, few if any of their tasks can be performed routinely at their own discretion except within a framework established by the "orders" of a physician who is ultimately responsible for the case. What they do is "ordered" and evaluated by members of the medical profession, and dependent upon the central diagnosis and prescription of medical treatment. This subordinate position in a medically dominated division of labor is the primary source, I believe, of the particular status of nursing as a profession. That its members are mostly women is a contributory but not primary source. Is it possible that an emphasis on the nurse's caring role can change the position of nursing?
NURSING IN THE HOSPITAL
¶27 I have argued that the two essential meanings that are fused into professionalism--caring and making a living--cannot be separated if the term is to have any special value. And I have tried to outline an ideal typical model that delineates both the distinctive structural elements of professionalism and its desirable virtues. Its emphasis is on discretionary judgment rather than on binding and mechanical rules of procedure, and on the quality of work rather than on its quantity or cost. Collegial relations are cooperative, based on a shared commitment to performing a special kind of work well. Relations with consumers are based on trust.
¶28 When we look at the real world of the hospital in which the nurse must work for better or for worse, however, we see that the nurse's capacity to exercise discretionary judgment is limited not only by medical dominance, but also by the bureaucratic rules and procedures established by the hospital administration, and by the resources that are available for doing her work. The intake, staffing and other resource allocation policies of the administration, as well as what might be called the structure of governance of the institution itself, have a profound influence on how nursing can be practiced. They limit the possibilities for giving care in a caring way, and for practicing ethically.
¶29 As Yarling and McElmurry put it, "nurses are not often free to be moral." (Yarling and McElmurry 1986: 63, italics in original) The graphic anecdotes they recount in their article show clearly how the organization of power and authority in the hospital can frustrate and even punish efforts on the part of a concerned nurse to correct the most egregious treatment decisions. It is for this reason that we must agree with them that if the fundamental moral problem of nursing is a consequence of the structure and policies of the social institution in which nursing is, for the most part, practiced, then any ethic that seeks to address this problem must seek reform of the policies and structures of that institution. An ethic that is concerned with structures and policies of social institutions is a social ethic. Hence, a nursing ethic must be first and foremost a social ethic. It must be one that seeks to free nursing practice from its 'hospitalonian captivity,' in the same way that the 1965 ANA resolution . . . sought to free nursing education from that captivity (Yarling & McElmurry 1986: 71, emphasis in original)."
PROFESSIONALISM AND NURSING
¶30 How can nursing be sufficiently freed to allow both caring practices, to use Benner's phrase, and the effective pursuit of a sensitive and responsible ethic? Nursing's subordination to both doctor's "orders" and the hospital administration is a function of two quite different things. In the former case it reflects its lack of autonomy in the health care division of labor due to its acknowledged and somewhat protected jurisdiction over technical skills whose practice is dependent on the physician's diagnosis and recommended course of treatment. The position of nursing as a profession would be enormously strengthened if it too could claim jurisdiction over a body of knowledge and skill that can be practiced independently of medicine, a body of knowledge and skill whose use is not contingent on the direction provided by medicine.
¶31 I rather doubt that this is a likely possibility, particularly in the case of bedside care. My guess is that nurses who contribute specialized, high-tech skills to the work of teams engaged in performing complex and highly demanding procedures are likely to be on a considerably more egalitarian footing with physicians than those who provide routine bedside care. Technical expertise requires its due in a closely functioning division of labor.
¶32 On the other hand, I do not see how "caring" can be persuasively claimed and defended as an exclusive resource of nursing, even in the rather special and complex way it is now being defined and discussed within the profession. Given the chance, every profession engaged in providing human services is likely to claim that it, too, is caring, and to have leaders who exhort its members to care in more than routine ways. And I would hope that everyone engaged in a human service would care, for caring is one indivisible element of the special meaning of professions and their mission. But I believe that what effectively establishes the strength of the various occupations is the specialized body of skill and knowledge over which each has exclusive command; what makes them professionals rather than technicians are the additional requirements that discretionary judgment based on some body of abstract theory rather than formally structured, close procedural rules guides the application of their knowledge and skill and that they may be trusted to care.
¶33 But while caring cannot provide the resources of an exclusive and defensible jurisdiction that might liberate nursing from the technical hegemony of medicine, it can provide the insight and energy that liberates nurses both from the often superficial and misinformed perspective of physicians who spend too little time with the patient, and from hospital policies often promulgated on the basis of considerations far removed from the bedside and the immediate welfare of individuals. Furthermore, caring reinforces the resolve to speak for the patient's needs and well-being independently of both physician and hospital. But caring cannot thrive without the nurturance and support of the institutional settings in which it is practiced. Nursing must struggle to realize the institutional conditions that allow its caring to be realized.
¶34 It might appear that the simple fact that most nurses are employed rather than self-employed puts them in an extremely vulnerable position that discourages their advocacy of the patient's good, and that if they were self-employed they could have more influence on the work they do. But self-employment in and of itself does not necessarily provide the circumstances in which one is free to practice caring. The autonomy it implies does not exist when the market for nursing services is glutted and highly competitive, or when it is controlled by physician or hospital patronage. Whatever the case for self-employment, however, it is likely that most nurses will remain employees. Indeed, more and more physicians are joining them as employees. The practical problem lies in finding ways of making employment more responsive to the needs of professionalism.
¶35 One of the most important issues facing all professions, not just nursing, lies in changing the position of professional employees in the organizations in which they work. In essence, professionals must gain the right to participate in determining those policies of their employing organizations that bear on their capacity to do good work for the benefit of their clients. Furthermore, their freedom to serve as advocate for clients and the public good must be protected from their vulnerability as employees. These circumstances must be created in part by new legislation on the federal and state level, in part by recasting the requirements for health care institutional licenses, charters and accreditation, and in part by the development of new modes of organizing and governing the professional and administrative affairs of the institutions employing professionals.
RECONSTITUTING PROFESSIONAL EMPLOYMENT
¶36 I am not in a position to provide a fully developed agenda for change, but I can make a few suggestions that bear on what I believe to be the most central issues. One thing that is needed is labor legislation that establishes unequivocally the right of professional employees both to bargain collectively and to participate in governing the institutions that employ them. Nursing, unlike medicine and many other professions, has gained the right to bargain collectively because of its unquestionable employment status and its limited participation in determining the policies of the workplace. However, my impression is that its collective bargaining has revolved primarily around the bread-and-butter economic issues of traditional American unionism--wages, benefits, job security, pensions, and to a limited degree, working conditions. But nursing must also have an organized and powerful voice in influencing policies that have been conceded by traditional trade unionism as the prerogatives of management.
¶37 Most professional employees are given considerably greater discretion in performing their tasks than other employees, and as I have shown elsewhere (Freidson 1988b: 158-84), they have considerably more voice in determining the work they do and how they do it. Indeed, in the Yeshiva decision of 1980 (see Freidson 1988b: 134-57, and Rabban 1989), the majority of the Supreme Court asserted that the professors of Yeshiva University determined the product to be produced (i.e., the curriculum), the clientele to whom it is to be offered (admission requirements), and other aspects of their work that are traditionally controlled by management. On that basis it ruled that professors who exercise such powers are to be legally considered managerial employees, and therefore not entitled to the protection of the National Labor Relations Act.
¶38 This ruling has effectively prevented the unionization of professors in private universities, (those in public universities having bargaining rights as state or other public employees), and it has been used to deny the protection of the NLRA to members of other professions. It was used, for example, to deny protection to physicians employed full-time by an HMO in California because they participated in what was defined as the managerial activity of quality review (Rabban 1989: 1831-2). This ruling requires professionals to either give up their participation in evaluating their own work, or their legal opportunity to exercise organized influence through collective bargaining over organizational issues affecting both their work and their living.
¶39 The first thing that is needed to rectify this situation is legislation that provides protection for professional employees who are engaged in both choosing and supervising their own activities and who wish to organize collective bargaining units. When such units exist, as they already do for a great many nurses, what should they concern themselves with? Of course they should be concerned with the traditional bread and butter issues, for one can hardly do any sort of work without making a reasonable living. But there is more to work than wages. I have argued elsewhere (Freidson 1988b: 134-57) that the critical dividing line between management and professional employees is--quite apart from the power to determine wages--the power to allocate the resources that one needs in order to do good work. Professionals might be free to control the work they do, but if insufficient resources are provided to them by management, they cannot do good work and they find their "autonomy" hollow. A high caseload with few if any supportive resources leads to "burnout," to cynicism and to soldiering, leads, in short, to efforts not to care.
¶40 Professionals should demand representation in the determination of the allocation of resources, including not only those nominally available, but also those the organization holds in reserve or siphons off to private investors. Furthermore, as professionals who have authoritative expertise at the level of service, they should be free to report to the public on the effect of restricting resources on the quality of the services it is possible for them to provide to those for whom they care. Insofar as there are profit-oriented employers, legislation should explicitly exclude the protection of competitively advantageous "trade secrets" that compromise the quality of the services they allow their employees to provide to the patients for whom they are supposed to care. Employees should be fully protected by "whistle-blowing" rights predicated on the doctrine that the first duty of the members of professions, consonant with the trust upon which their privilege is based, is to their clients' well-being and the general good rather than to their personal advantage or the material interests of their employers and supervisors.
¶41 Related to the legislation that protects professional employees who seek to advance the interests of their clients and the public even when it is to the disadvantage of their employers is the legal and quasi-legal body of regulation involved in chartering and accrediting the institutions in which they work. Some of those charters for health care organizations specify the way the medical staff is to be organized and represented to governing boards. In order to empower nursing to be more free to practice caring, the organized profession needs also to try to change the substance of those charters to give it a stronger voice on their governing boards.
¶42 But while there is no substitute for those legal and quasi-legal changes in the formal constitution of employing organizations, it should not be forgotten that there can always be a great deal of important variation that can occur within those legal forms. Even in industry there is, today, a great deal of experimentation going on in organizing the relations among those who do the productive work and those who are presumed to manage them. The ideal typical bureaucratic form of organization is less common in reality than one might at first glance assume. Stimulated by the extraordinary changes now going on in American health care institutions, organizational theorists have already been trying to conceive of new forms that are better suited to both the new realities and to the need for truly professional care that lies at the heart of the system. (See, for example, Scott 1982 and Shortell, 1985, though they address themselves primarily to the medical staff.) Nursing might do well to encourage such thinking on its own behalf in order to develop a reasoned program of organizational change for gaining its rightful place in the professional control of the terms of caring.
¶43 Finally, I might say that in considering how professional services should be organized in light of the ideal typical model I have sketched, it is essential to understand that in reality professionalism is itself subject to corruption by the self-interest of professionals as individuals, and by collegiality itself. Professions have been rightly criticized for their abuse of their economic monopoly and for their reluctance to police their own ranks. There is thus no question that it is appropriate for social policy to employ both market-oriented and bureaucratic devices to assure professional accountability, and that professionals themselves should cooperate with those likely to assure the quality of care. Used in moderation, such devices provide appropriate and necessary correctives to some of the self-protective tendencies that we can assume are to be found in all human groups.
¶44 But professionals should never forget that excessive emphasis on cost and standardization is antithetical to the emphasis on quality and caring discretionary judgment that lies at the heart of their mandate. Cost and standardization thrive at the expense of collegial and client trust and of the capacity to take caring responsibility. Instead of accepting the increasing extension of hostile elements of free market and bureaucratic control into professional affairs, they should struggle for the right to themselves exercise responsible control over both cost and the quality of the care down at the workplace, where the needs of concrete people are served individually by the exercise of caring judgment. There is the crux of the matter: if professionals are really to be professionals, they must exercise control over their own work responsibly, in their own way, and in the interest of their clients. The caring nurse, no less than the caring physician, must make sure that the institutions in which they work provide the conditions by which they can do so.
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